Roots Client Weekly Update Client Name* First Last Primary Counselor*Select your counselor hereRashad HameedVictoria LindleyMikare MichiraKaonou VueRachael CavegnOtherTREATMENT DETAILSCurrent Phase*OneTwoThreeFourLegacyAttendance Days* Monday Tuesday Wednesday Thursday Friday Are you in a recovery residence?*YesNoWhich one?*Move-in Date:* Date Format: MM slash DD slash YYYY Stipend Level:*Full Stipend3/4 Stipend1/2 Stipend1/4 StipendN/A - No StipendSUBSTANCE USE & WITHDRAWAL ASSESSMENTWhat is your last date of substance use?* Date Format: MM slash DD slash YYYY What did you use on that date?*Have you consumed any of the following substances since your last update?*Check all that apply Alcohol Marijuana Benzodiazepines Heroin Opiates/Opioids Methamphetamine Ritalin/Adderall/Etc Cocaine Molly/MDMA Inhalants Salvia LSD/Hallucinogens Synthetic Cannabis Bath Salts/Cathinones Kratom Steroids DXM/Cold Meds GHB Methadone Suboxone/Subutex Pseudoephedrine Caffeine Nicotine Other OTC Meds Other Substance None of the above Are you currently receiving medication assisted treatment?*Not on MATOn MethadoneOn SuboxoneOther MATWhat is your current dose?*How long have you been at this dose?*Please describe any withdrawal symptoms you may be experiencing:PHYSICAL HEALTH & WELLNESSPlease rate how physically “well” you have felt this week:*GreatGoodJust OkNot GoodAwfulExplain:*Any new medical/health issues?*YesNoDescribe:Sleep Quality?*GreatGoodJust OKNot the BestAwfulHow many hours per night?*Have you been eating regular, quality meals?*YesNoWhat's getting in the way?Any medical/dental appointments this week?*YesNoWhat/When?Please list any new physical health meds or medication changes:*If applicable, do you take your medications as directed?*YesNoNot ApplicableDo you get regular physical exercise?*YesNoDescribe:*EMOTIONAL, BEHAVIORAL & MENTAL HEALTHWhat was your biggest accomplishment this week?*Have you had any thoughts of self-harm this week?*NoYesHave you acted on any thoughts?*NoYesPlease talk to a staff member as soon as possible!Rate your overall mood this week:* Great! Good! Just Ok Pretty Bad AwfulRate your overall stress level this week:*Very LittleA LittleMediumToo Much!Extreme!Biggest stressors this week:*Name two coping skills you’ve used this week:*Do you take your psychiatric meds as prescribed?*YesNoNot ApplicableAny mental health appointments this week?*YesNoWhat/When?*What were some significant events for you this week?*RECOVERY MOTIVATION AND PARTICIPATIONWhat is your primary motivation for being in recovery/treatment?* My Own Goals/Health Probation/Courts Child Protection Housing Family/Partner Something Else How excited have you been for recovery this week?*Very!Excited!So-SoUgh!Noooo!Please tell us how excited you've been to do the following activities this week:Treatment Group:*Attending and Sharing in GroupVery!Excited!So-SoUgh!Noooo!Other Treatment Appointments:*Individual Counseling, Therapy, Peer SupportVery!Excited!So-SoUgh!Noooo!Other Recovery Activities:*Recovery Meetings, House Meetings, ProbationVery!Excited!So-SoUgh!Noooo!What group did you enjoy most this week?*Least?*How did you participate in the group process?*What is your biggest recovery goal right now?*RELAPSE PREVENTION/RECOVERY MANAGEMENTHow confident have you felt in your recovery?*Extremely ConfidentVery ConfidentSomewhat ConfidentNot Very ConfidentNot at All ConfidentPlease identify any triggers that you’ve experienced this week:*Check all that apply Using Friends Family Members Partners/Spouses Bars/Clubs Old Neighborhoods Seeing Drugs/Alcohol Social Situations Celebrations Dining Out Movies/TV Sexual Encounters Money Holidays Ads/Marketing Stress Sadness Depression Frustration/Anger Irritability Dishonesty Loneliness Overconfidence Guilt/Shame Self-Loathing Discrimination/Prejudice Legal Issues Negative Thoughts Fear of Failure Wanting to Feel High Wanting to Feel Better Criminal Thrill-Seeking Longing for the Old Lifestyle Wanting to Belong Other: Have you been having trouble with any of the following behavioral challenges?*Check all that apply Overeating Restricting Food Binging/Purging Sexual Behavior Spending/Shopping Gambling Video Games Repetitive Behaviors Compulsions/Obsessions Cutting/Self-Harm Compulsive Cleaning Excessive Exercising Hair Pulling/Skin-Picking Other Compulsive Behaviors None of the Above Please list two coping skills you’ve used to help stay on track:*What/whom was most influential in your recovery this week?*RECOVERY ENVIRONMENT, RELATIONSHIPS & SUPPORT NETWORKAre you in a romantic relationship?*NoYesIf so, How long?How many supportive relationships do you currently have?*15+10+5+A handfulNoneWho do you consider your primary support at present?*How often do you call/text/chat with your support network?*Daily2+ x/WeelWeeklyWhen NeededNot OftenHow often do you spend face-to-face time with your support network?*Daily2+ x/WeekWeeklyWhen NeededNot OftenHow often do you attend mutual/recovery support groups?*Daily2+ x/WeekWeeklyWhen NeededNot OftenDo you have a sponsor/recovery coach?*YesNoWorking on itHow often do you talk to them?Rate how “connected” you feel to others around you:*VeryQuiteJust OkNot VeryNot at allWhat are you doing for fun/recreation?*How are things with your sober house leader/peers?*GreatGoodOkNot the BestAwfulN/ADo you have any probation/court/CPS meetings coming up?*NoYesDetails:*Are you following all of your legal requirements?*NoYesN/AAny new charges/arrests?*NoYesIf it applies, how is work/school going for you?*GreatGoodOkNot the BestAwfulN/APlease rate your relationship with your counselor:*The BestPretty GoodJust OkNot the GreatestTerribleWhat can they do to improve the relationship?*What can you do?*What do you like most about this program?*Least?*What would make the program better?*Anything else you’d like us to know?